A young demonstrator shows support for Tony Lester, who died in an Arizona prison.
Photograph: Lester family

When Patti Jones answers the phone, the energetic whirlwind immediately plunges into a story she’s told many times over – and is willing to tell as many times as it takes. Her nephew, Tony Lester, killed himself while in the custody of the Arizona department of corrections (ADC) in 2010, triggering a wrongful death suit, pressure for statewide reforms on the handling of mentally ill prisoners, and a trip to Washington to participate in congressional hearings on solitary confinement practices in American prisons.

“Since Tony’s death I have not stopped,” she says, “and I want to ensure that this never happens again. This is a way of life in the [ADC].” Her nephew’s death radicalized this prison reformer, turning her into a force of nature who nearly explodes over the course of our conversation, frustrated with what she sees as needless hangups in the prison system.

Tony Lester. Photograph: Lester family

The story she tells is one of acute familiarity in US prisons, which have turned into warehouses for mentally ill people. Lester, like the estimated other 43 inmates who killed themselves between October 2005 and April 2011 under the eye of the ADC, ended up on a collision course with fate almost as soon as he entered an Arizona prison.

Six weeks after intake and processing, Lester was on suicide watch as his untreated severe mental illness pushed him into a break with reality. Two days after being released from this watch, he had slit his wrists in his cell with the razors a member of the prison’s staff carelessly gave him in a personal hygiene kit.

His story would have faded into the background of similar cases but for the determination of his family, particularly Jones, who is dogged and relentless when it comes to justice for mentally ill prisoners. Wendy Halloran, an award-winning investigative reporter at Arizona’s 12 News, took up Lester’s cause as well, pushing it on to the national stage thanks to her fearless and aggressive journalistic career.

Lester’s story started in high school, as the Native American youth began to experience early signs of schizophrenia. Jones explains that he had “seven different voices he was trying to cope with, including one telling him to kill himself”. By 23, he was experiencing severe untreated mental illness, and at a party with friends, he attempted to kill himself with a knife, sparking a scuffle that injured two women and sent him to court on aggravated assault charges.

“The sad part of that whole thing is that when he went to court, he didn’t open up to his attorney because he was paranoid. The voices told him not to trust his attorney,” Jones says, describing the erosion of Tony’s one obvious defense, and opportunity to get help.

Lester didn’t say anything until after he was convicted, forcing his attorney to backtrack in an attempt to get mental health services for his client. Ultimately, he was rerouted to a rehabilitation program so the state could stabilize him for sentencing, but when he returned to the Maricopa County court, he received a 12-year sentence, and began his brief time in prison, starting out in the general population.

Demonstration in support of Tony Lester. Photograph: Lester family

Lester was a victim of a common practice in the US, which offers mental health diversion courts in only a handful of communities. Such courts provide opportunities for rehabilitation through therapy, mandated treatment, and placements in the community. The goal, as with drug courts – an innovation dating to the 1980s designed to keep low-level offenders out of prison – is to make mentally ill offenders productive members of society, rather than exacerbating their mental illness in the prison system.

Mary Lou Brncik, founder of David’s Hope, an organization promoting better interactions between mentally ill people and the justice system in the state, believes mental health courts are critical for addressing the growing numbers of people passing through the system each year.

In the pages and pages of court filings associated with Parsons versus Ryan, the class-action suit brought by the ACLU and the Arizona Center for Disability Law in the name of Arizona prisoners suffering from poor conditions, the same themes repeat themselves from expert opinion to expert opinion.

What they found was a system in chaos. Dr Brie Williams found exercise enclosures that were far too small, along with inadequate cooling systems at prisons. For patients on psychotropic medications, cooling and access to water are a particularly acute issue, as they can overheat directly and experience stroke and death. Dr Pablo Stewart echoed her findings, noting that: “The healthcare currently provided in the ADC does not meet the minimum standards of care.” Stewart also identified inappropriate use of chemical agents like pepper spray against mentally ill prisoners, a finding several experts concurred with – one noted that cans of pepper spray were casually left out with the specific purpose of intimidating prisoners.

In Stewart’s review of prison conditions, he found that many mentally ill prisoners were stuck in solitary confinement, an issue of particular concern to Craig Haney, an expert in solitary confinement and prisoner welfare. He pointed specifically to the fact that severe mental illness can be heavily exacerbated in solitary, making it particularly dangerous for mentally ill prisoners – in fact, the American Bar Association has spoken out against the practice in briefing papers on the treatment of prisoners.

Former corrections administrator Eldon Vail, also called by the plaintiffs to evaluate conditions in the Arizona department of corrections, was horrified by what he found. In his detailed observations and conclusions, he was perturbed by the abuse of solitary confinement and segregated housing units. He also noted practices clearly intended to intimidate and frighten prisoners, such as routinely wearing unnecessary personal protective equipment. While working with prisoners to evaluate the diet provided in Arizona prisons, he says, prisoners were “insistent” on showing him their combination sack breakfast/lunches, which contained little more than bread and a slab of “mystery meat”.

Vail noted that many prisons engaged in caloric restriction to control and subdue prisoners, a practice that is clearly used at the Arizona department of corrections, and the results are extreme. The prisoners he interviewed complained of weight loss, and by comparing their photographs at intake with their current condition, he agreed with them – the difference was dramatic, with prisoners not only losing weight but also muscle mass because they were not able to exercise in narrow, confined exercise yards with limited fresh air.

If the conditions in Arizona prisons sound hellish, perhaps the most grim testimony can be found in the ADC’s refusal to allow Amnesty International to tour its facilities while the organization prepared a report on the subject. Instead, Amnesty drew on testimony from prisoners, staff and advocates as well as official ADC manuals and documentation. The ADC did not respond to the report, which included accusations of incredibly poor hygiene and disintegrating physical plant conditions, a problem noted by expert witnesses in Parsons versus Ryan who were able to enter Arizona prisons.

According to reports from those Amnesty International interviewed, infections such as staph are common, with filth smeared across the walls of Arizona prisons and limited measures to promote cleanliness, creating untenable living conditions. Moreover, the organization noted that an estimated 36% of Arizona inmates experience severe mental illness, and many of them, like Lester, receive little to no treatment.

Jones describes being stymied at every turn by prison officials who refused to compel him to take his medications despite requests from his family, and witnessing a rapid decline in her nephew’s condition. Late on 11 July 2010 family members received a call reporting that he had been taken to the prison infirmary with “non life-threatening injuries”. Hours later, the prison was calling with an update: he was dead.

The prison, Jones says, was lying about the circumstances of his death, which was caught on video. Over the course of a chilling and horrific 23 minutes, guards can be seen identifying Lester in medical distress and refusing to render aid beyond telling him that assistance is coming. By the time he was transferred to the infirmary, his blood loss would have been severe – Lester had slashed not only his wrists but his jugular vein and groin. Prison officials certainly knew that his injuries were probably fatal before they called his family.

The voice urging Lester to kill himself had won as Lester slipped through the cracks of a prison system that didn’t enforce its own requirement that “health records be reviewed within 12 hours of an inmate’s arrival”, according to Dr Robert Cohen, who provided an expert report for the plaintiffs in Parsons versus Ryan; he, along with other witnesses, also noted that prisons were short-staffed and unable to provide sufficient medical treatment.

Stewart’s report found that there were not enough mental health professionals to meet prison needs, that prisoners were not adequately monitored while on psychiatric medications, and that nurses routinely ignored medical orders including so-called “watch swallow” orders, which require nurses to confirm that prisoners have swallowed their medications. He specifically accused the ADC of failing to prevent suicides like Lester’s, and moreover noted that medical records were sloppy and in some cases actually altered; one of his findings was an autopsy report dated two days before a prisoner’s suicide.

For Lester’s family, the pain of a family member’s death wasn’t over. In a search for answers from the prison, they were stonewalled, with the prison refusing to even allow them to watch the video they knew existed, thanks to Wendy Halloran (the full video isn’t available to the public due to a shield order sought by the ADC). Jones and her sister Eleanor Lester were only permitted to watch the video, shot by guard Umberto Hernandez, in chambers. According to Jones, medical officers didn’t arrive for nearly 12 minutes.

Timestamps on the video provided a damning version of the story of Lester’s suicide that didn’t align with that the ADC told. They indicated that Lester was found much earlier than originally claimed, and that the warden didn’t arrive at the unit for nearly an hour and a half after the suicide attempt was reported. “What they say the truth is and what it is are not even close,” Jones says, with a note of bitterness.

Ultimately, the family’s wrongful death suit was settled out of court, but Jones continues to campaign for better conditions in Arizona prisons and across the country. She wants to see what she refers to as “Tony’s Law”, establishing a protocol for handling mentally ill people at prison intake to ensure they are identified and provided with specialized care. Jones also favors the use of mental health courts to route clinically ill people to more appropriate venues than prisons, and has traveled to Washington DC to testify against the use of solitary confinement in American prisons as part of her crusade for prison reform.

Parsons versus Ryan was also settled out of court, in October 2014, with the ADC agreeing to reforms in prison policies and conditions to address concerns about mentally ill inmates. The settlement mandates adherence to over 100 individual measures of healthcare performance and ongoing monitoring and oversight.

For Jones, the ACLU outcome is only a part of a larger picture in a country with a sprawling prison system and serious healthcare shortcomings, and she has vowed not to rest until she has seen the reforms she is pushing for, even if she is heartened by slow changes in the correctional landscape.

“He was a brilliant man, went to college preparatory school, was on the honor roll,” Jones says. “He wanted to become a psychiatrist. That was what he really wanted to do.”